With velocity one would not expect of a zombie, the last-chance GOP bill aimed at partially repealing and replacing Obamacare, the Graham-Cassidy proposal, is suddenly being taken seriously by friends and foes alike. The main agent of propulsion was a Senate GOP luncheon yesterday after which Mitch McConnell expressed support for the measure and his deputy John Cornyn offered to get a whip count in place. Lindsey Graham says the bill if voted on right now would get “47, 48 votes,” which is of course dangerously close to the 50 needed to rescue the debacle of GOP health-care efforts.
The bill is being advertised as a “state flexibility” approach to solving the problems national health-care legislation has allegedly caused or failed to resolve. It would take all the money currently being made available for both the Medicaid expansion and the tax credits Obamacare created for buying individual health insurance on the exchanges, and dump it all (after a healthy cut and a redistribution of funds to shift money toward states that did not expand Medicaid) into a block grant. The block grant could be used for any health-care purpose, without any guarantees for the people who had been covered under the Affordable Care Act. States could not, however, reenroll people covered in the expansion in Medicaid; they’d have to cover them some other way, presumably via private insurance.
The Graham-Cassidy bill also is a vehicle for a radical restructuring of the entire Medicaid program, a goal the GOP has been pursuing for decades. Medicaid would be subjected to a per capita cap, and states would have the option to turn the whole program into a block grant with all federal coverage requirements eliminated (a particularly dire threat for poor people in deep-red states). The pursuit of state-level flexibility extends to Obamacare, where of many of the regulations governing individual health insurance would become optional, including the individual and employer mandates and the bans on price discrimination against old and sick people.
All in all, this bill contains most of the nasty provisions of the House and Senate versions of Trumpcare, all obscured by a cloud of “state flexibility,” which mainly constitutes permission to cut benefits or drop coverage. So why is there a sense of renewed momentum for this last-gasp bill?
The key reason for guarded GOP optimism is the close friendship between Lindsey Graham and John McCain, who administered the coup de grâce for the July health-care push. The Arizonan has sent very mixed signals on the bill, however, supporting it on the merits but also demanding it proceed through “regular order,” meaning hearings and full floor debate. That definitely ain’t happening, for two reasons: the Senate parliamentarian has already ruled the budget resolution that authorizes a 50-vote health-care bill will expire on September 30, and the time for debate on said bill was used up in July. So if Graham-Cassidy is going to be passed, it will happen very quickly (the current plan is for a vote during the week of September 25, or in other words, at the very last minute).
With Rand Paul, who stuck with his party on the definitive vote in July, having already announced opposition to Graham-Cassidy, sponsors would need McCain and one other senator in order to get the bill across the line. That will be tough. It’s hard to imagine Susan Collins suddenly relenting in her opposition to virtually every GOP health-care bill of the recent past. Yes, she co-sponsored a bill with Cassidy earlier this year which bears a superficial resemblance to Graham-Cassidy. But it did not include the kind of deep Medicaid cuts and elimination of Obamacare tax subsidies that characterize the more recent effort. As for Lisa Murkowski, who resisted all sorts of attempted bribes and threats to get her to toe the line in July, it’s also hard to see a clear path for her to go along to get along. But we have no way of knowing what kind of fresh inducements might be offered for the last couple of votes, and Graham-Cassidy would definitely generate enough budget savings to fund some pretty lavish bribes.
The accelerated timetable for consideration of Graham-Cassidy means the drip-drip-drip of individual senators being pressured to publicly declare their intentions, with provider groups (the bill is already being opposed by the American College of Physicians), citizens, and state governments pressuring them to say “nay,” may not be replicated. One would normally figure a CBO impact estimate — expected to come out at the end of next week, right before the bill heads to the floor — might devastate support for this legislation. After all, it seems very likely that a bill with an elimination of the Medicaid expansion and of insurance-purchasing tax credits, a Medicaid per capita cap, and a state option to kill key insurance regulations, would be adjudged as eliminating health insurance for 20-million-plus Americans, just like the previous GOP bills.
There’s a rumor going around, however, that CBO will announce it only has time to estimate the impact of Graham-Cassidy on the federal budget before the vote is cast. The Senate parliamentarian will likely say that’s all the Congressional Budget Act requires, and the deal could go down before the public becomes aware of the full impact on insurance coverage or premiums.
If all this happens, and the bill gets 50 votes, and Mike Pence breaks the tie, amid an outbreak of Republican joy commensurate with the Democratic happiness on July 28 when John McCain made his famous thumbs-down gesture, the House will be put in a real bind. The lower chamber is not constrained by the Senate’s September 30 deadline, but once it passes, there can be no further Senate votes. That means the House would quite literally be forced to take Graham-Cassidy or leave it as is. By then, it’s entirely possible CBO will have completed an assessment of the bill’s impact on coverage and premiums, which will likely be god-awful. And while relatively few Republican senators will be discomfited about the Graham-Cassidy block grant funding formula that shifts dollars from Medicaid expansion to non-expansion states, there are quite a few GOP House members from the states hit hardest, like California and New York.
I’m sure there are more than a few House Republicans who privately hope this final spasm of Senate activity aimed at repealing and replacing Obamacare subsides as quickly as it arose. But there remains a very small but real possibility that the biggest regrets will be felt by congressional Democrats who cleared the Senate decks for Graham-Cassidy by cutting a fiscal deal with the White House.